Overview of the AUC Program: How Did We Get Here and Where Are We - - PowerPoint PPT Presentation

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Overview of the AUC Program: How Did We Get Here and Where Are We - - PowerPoint PPT Presentation

May 02, 2023 473 likes •602 views

Overview of the AUC Program: How Did We Get Here and Where Are We Going? 1 Legislative Origins 2014 Protecting Access to Medicare Act The doc fix legislation created a program that requires physicians to use a CMS-approved tool to

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SLIDE 1

Overview of the AUC Program:

How Did We Get Here and Where Are We Going?

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SLIDE 2

Legislative Origins

  • 2014 Protecting Access to Medicare Act
  • The “doc fix” legislation created a

program that requires physicians to use a CMS-approved tool to consult appropriate use criteria when ordering advanced diagnostic imaging services.

  • It all sounds so simple….
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SLIDE 3

The AUC Program In Practice

Creates a complex process for ordering and furnishing an advanced diagnostic imaging test

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Clinician consults AUC using Qualified CDSM (Clinical Decision Support Mechanism)

Decision support number generated from CDSM Order placed; AUC indication can be

  • verridden

Test Furnished Furnishing clinician reports AUC consultation on claim form

NO DOCUMENTATION NO PAYMENT

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SLIDE 4

Clinical Decision Support Mechanisms

  • Health care professionals who order advanced

imaging tests (SPECT, PET, CT, MR) must consult AUC through a qualified Clinical Decision Support Mechanism (CDSM)

  • CDSMs are the electronic tools through

which clinicians access AUC – Either embedded in EHR or a standalone system

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SLIDE 5

Sites of Service

  • Clinicians in the following sites will be required

to consult AUC:

  • Independent diagnostic testing facilities
  • Hospital outpatient departments

– This includes the ER

  • Physician offices
  • Ambulatory surgical centers
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SLIDE 6

Exceptions

  • Emergency conditions
  • Medicare Part A claims
  • Significant hardships
  • EHR and/or CDSM vendor issues
  • Insufficient Internet access
  • Extreme, uncontrollable events
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SLIDE 7

Outlier Policy

Identification of

  • utlier

professionals will initially be based

  • n consultation of

AUC for priority clinical areas Approximately 5%

  • f providers will be

identified as

  • utliers

These outliers will be subject to prior authorization

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SLIDE 8

Medicare’s AUC Program

Do we really need it?

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  • Quality
  • Cost
  • Improvement

Activities

  • Advancing Care

Information

  • Downside Risk

— Quality & Cost

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SLIDE 9

Imaging Volume

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Source: Medicare Payment Advisory Commission, March 2018

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SLIDE 10

Challenges to Implementation

  • Which AUC will your hospital or practice

select?

  • Possibility for discordance if more than
  • ne AUC is embedded in the CDSM

– Winchester et al. (2016) found 52% of 67 ACCF ratings couldn’t be matched to an ACR rating

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SLIDE 11

Challenges to Implementation

  • The education component is unclear
  • Providers receive a yellow or red

stoplight when ordering an uncertain or inappropriate test – The AUC program does not counsel providers on the clinical indications that are uncertain or inappropriate

  • Some AUC include cost and radiation icons,

leading to concerns regarding test substitution

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SLIDE 12

Timeline

  • CMS regulations indicate an educational and

testing year to begin in 2020

  • This testing phase will address outstanding

technical coding and billing concerns

  • CMS will not deny claims if they do not contain the

proper AUC consultation information

  • CMS has acknowledged uncertainty regarding

whether claims without AUC consultation implementation information will be paid

  • CMS will issue clarifying language in May

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